Supervisor'S Investigation Report Form Page 2
ADVERTISEMENT
1
2Employee Injuries
If the employee requires emergency medical attention, call 911 or proceed to the nearest emergency room.
If the employee requires non-emergency medical attention, the employee should be seen at a Miami-Dade Authorized Care
Center
(or call 305-375-4280).
All employee injuries or illnesses must be promptly reported to Teleclaim 1-877-MDC-RISK/877-632-7475 or, if there is no
medical attention or lost time, on the Minor Injury Log (available from Safety website).
If the incident results in death, serious injury, or serious damage, promptly notify the Miami-Dade Office of Safety at 305-876-
8000 (after hours 305-546-1419) and ISD Risk Management at 305-375-4281.
The Supervisor’s Investigation Report In
accordance with the Miami-Dade County Safety Manual, every employee injury will be
investigated by the employee’s supervisor as soon as possible after the occurrence, and reported on the Supervisor’s Investigation Report.
For assistance contact the Departmental Safety Representative or the Office of Safety (305-876-8000).
How to Conduct an Accident Investigation
1. Check the Scene
a.
Carefully examine the site of the incident, equipment and conditions.
b.
Reconstruct, when possible, the chain of events leading to the incident, and determine what caused the incident.
2. Collect the Evidence
a.
Inspect machinery, protective equipment, site conditions, etc., to determine cause or contributing factors.
b.
If equipment or machine parts were defective, remove them from use, tag and disable damaged or defective equipment, and
contact your Departmental Safety Representative or the Miami-Dade Office of Safety (305-876-8000) for instructions. Do not
return defective or damaged equipment to service.
3. Interview the Employee
a.
Ask the employee to start from the beginning and describe what happened.
b.
Determine what procedures were (or were not) followed, what equipment was used, etc.
c.
If employee exhibits unusual or erratic behavior, contact your Division Director or DPR immediately for instructions.
d.
Provide the employee’s description of the accident in the appropriate section of the Supervisor’s Investigation Report.
4. Interview Witnesses
a.
Interview witnesses at the scene. (Whenever possible, interview witnesses separately.)
b.
Obtain witness name, address, phone number and statement. Attach additional paper if necessary.
5. Write It Down, Take Photos, Make Sketch / Diagram
a.
Utilize the Supervisor's Investigation Report form to document all information. Attach additional paper if necessary.
b.
Describe unsafe conditions, faulty equipment, procedures not followed, improper use of equipment, weather or other items
which could have caused or contributed to the incident.
c.
Attach (and number) photos, diagrams, statements and other pertinent information to the Supervisor’s Investigation Report.
6. Review and Submit the Supervisor’s Investigation Report
a.
Review the information. Is it complete and adequate? If necessary, conduct further questioning of employee or witnesses.
b.
Within 48 hours of the incident, forward the Supervisor's Investigation Report and any additional information to: ISD Risk
Management, Suite 2340, 111 NW 1 Street; Phone: 305-375-4280 / Fax: 305-375-5492. Submit copies to your Departmental
Safety Representative and in accordance with your department’s protocol.
ISD RISK MANAGEMENT INVESTIGATION All County personnel shall cooperate fully with ISD Risk Management staff conducting accident or
incident investigations. ISD Risk Management investigations may be conducted in addition to, and independent of, departmental
investigations or other investigations.
Miami-Dade Office of Safety, Risk Management, ISD Phone 305-876-8000
Safety Website
Rev. April 2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business